LoGrasso Hall
Fredonia, NY 14063
Tel: (716) 673-3424
Fax: (716) 673-3140
Rights, Privacy, Responsibilities and Consent
for Treatment of a Minor
Your son or daughter is requesting treatment at the Fredonia Counseling Center.
However, because they are under 18 years of age, parental consent is necessary
for them to receive counseling and psychological services. The purpose of this
form is to describe the services offered and inform you of your and your child’s
rights and responsibilities regarding our services.
1. Eligibility
Counseling services are available to currently enrolled, full- and part-time Fredonia
2. Services Available
At the end of the initial assessment, if further services are indicated, the counselor may
group, individual, or couples counseling, suggest further evaluation, or refer a
student to other services on- or off-campus. Occasionally, some students find that the
initial consultation meets their needs and require no further services.
We offer a range of services, including group counseling, short-term individual, and couples
counseling. A student has the right to refuse diagnostic or treatment services. The counselor
may be a Licensed Mental Health Counselor, Licensed Marriage and Family Therapist,
Licensed Social W
orker, or a graduate student under the supervision of the professional staff.
3. Prompt Service
A student will be seen for services in a timely manner. Same-Day Triage appointments are
available on a first come, first-serve basis. If, however, a student experiences a crisis before
being assigned to a counselor, they should contact the Counseling Center, and articulate the
urgency of their concern, so that crisis services can be arranged.
4. Respect
Counseling Center staff will respect each student as an individual and convey this respect
by providing quality care, keeping appointments, or contacting the student if a change in
time is necessary, and by giving complete attention during sessions.
1. Privacy
Information shared by a student will be kept in strict confidence. The Counseling Center
creates and maintains records describing physical and mental health history, symptoms,
diagnoses, treatment, and plans for future care or treatment. Most disclosures of private
information would require both student and parental permission. Because the professional
counseling staff operate as a team, we may confer with each other as professionally necessary
to provide the best possible service to a student.
2. Disclosures that do not require a parent or student’s permission
Child Abuse: If, in our professional capacity, it comes to our attention that a child is abused/maltreated, we
must report such abuse/maltreatment to Child Protective Services.
Emergency Situations: We may use or disclose information about a student if we are unable to obtain
parental consent yet emergency treatment is needed. If this happens, we will try to obtain parental consent
as soon as we reasonably can after providing or arranging for treatment.
To Avoid Harm: We may disclose information about a student to protect the student or others from a
serious threat of harm by the student.
National Security: We may be required, by federal law, to disclose information about a student to federal
officials for intelligence and national security activities.
Release of Information to Parents or Guardians: While your child is a minor, you have right to discuss
your child’s counseling with her/his counselor. Once a student reaches the age of 18, he or she will be asked
to complete a new consent as a legal adult. After your child turns 18, you can ask her/him give the counselor
written permission to allow two-way communication between yourself and the counselor. If your child does
not sign such
a release at that time, you can communicate information to the counselor, but the counselor
will not be able to confirm whether or not your child is continuing in counseling or talk to you about your
child’s counseling experience.
Lawsuits and Disputes: We may disclose information about a student if we are ordered to do so by a court
or administrative tribunal.
1. Participation
Active participation in the counseling process is necessary for progress to be
made. It is important
that a student notifies the counselor if problems worsen.
2. Cancellations
It is the student’s responsibility to keep scheduled appointments, unless rescheduled or canceled at
least 24 hours in advance.
3. Feedback
The Counseling Center staff is interested in any positive or negative feedback, students may have
regarding the services received. We periodically ask students to complete an anonymous evaluation
asking for feedback about our services. If for any reason a student is not satisfied with the
counseling process, we encourage that person to discuss this first
with his or her counselor. If
concerns are not resolved to a student’s satisfaction, the student may request an appointment with
the Clinical Director of Mental Health Services to discuss possible reassignment or
other counseling
I am the parent or legal guardian of ________________________________.
nt’s Name (Print)
I have received a copy of the Fredonia Counseling Centers Parental Consent for Treatment form. I have read
and fully understand the information contained in this form. I hereby give my permission to the professional staff
the Fredonia Counseling Center to engage in counseling services with my minor child.
Student’s Name (Print)
Student’s Date of Birth
Name of Parent/Legal Guardian (Print)
Signature of Parent/Legal Guardian
This form will be faxed,
mailed or
emailed to a parent.
Please return the
form to the Fredonia Counseling
Center to the fax number
or postal
address on this
form or in an email
attachment to
student's counselor.
The counselor
may also
elect to verify parental consent upon receiving the
consent form.
click to sign
click to edit